Bleeding Control (B-Con)
Basic Copyright © 2017 by the American College of Surgeons
Overview
Mass Casualty Incidents (MCIs):
3-fold increase in number of active shooting events since 2008
50% occur at businesses and 33% in schools
50+ domestic terrorist attacks since the Oklahoma City Bombing in 1995
294 mass shootings in 2015 alone, more than one per day, is unfathomable.
45 shootings at schools and over 142 such incidents during which a firearm is discharged in a school building or on a school campus since the Sandy Hook Massacre.
Hemorrhage Control Saves Lives:
35% of pre-hospital deaths due to hemorrhaging
40% of deaths in the first 24 hours after a traumatic event is due to hemorrhaging
20 minutes to hours for medical professionals to arrive on scene or for patients to be delivered to medical facilities
Using these concepts, the military has substantially decreased battlefield deaths.
What everyone should know to
control bleeding Bleeding Control Basic v. 1.0
This educational program is the product of a cooperative effort by:
The Hartford
Consensus
The American
College of
Surgeons
Committee on
Trauma
The Committee
on Tactical
Combat
Casualty Care
The
National
Association
of
Emergency
Medical
Technicians
• The focus of this program is on:
Introduction | Principles | A-Alert | B-Bleeding | C-Compression |
- The immediate response to bleeding
- Recognize life-threatening bleeding
- Appropriate ways to stop the bleeding
• The help given by an immediate responder can often make the
difference between life and death, even before professional
rescuers arrive.
With the right training, YOU can help save lives!
WARNING! Some of the images shown
during this presentation are graphic
and may be disturbing to some people.
Bleeding Control Basic v. 1.0 Introduction | Principles | A-Alert | B-Bleeding | C-Compression |
Why Do I Need This Training?
Work-related injuries
Motor vehicle crashes
Mass shootings
Bombings
Home injuries
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles of Immediate Response
• Ensure your own safety
• The ABCs of Bleeding
A – Alert – call 9-1-1
B – Bleeding – find the bleeding injury
C – Compress – apply pressure to stop the bleeding by:
1. Covering the wound with a clean cloth and applying pressure by
pushing directly on it with both hands, OR
2. Using a tourniquet, OR
3. Packing (filling) the wound with gauze or a clean cloth and then
applying pressure with both hands
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
Safety
• Before you offer any help, you must remain safe
• If you become injured, you will not be able to help the victim
• Initiate care if the scene is safe for you to do so
• If, at any time, your safety is threatened, attempt to remove
yourself from danger and find a safe location
• Protect yourself from blood-borne infections by wearing
gloves, if available
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
A • Alert
Get help
• Call 9-1-1 yourself, OR
• Tell someone to call 9-1-1
Alerting 9-1-1 will notify and get emergency medical responders and,
depending on the situation, police officers to respond to the scene
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
Find where the victim is bleeding from
• Open or remove the clothing so you can see the wound
Look for and identify “life-threatening” bleeding
• Blood that is spurting out of the wound
• Blood that won’t stop coming out of the wound
• Blood that is pooling on the ground
• Clothing that is soaked with blood
• Bandages that are soaked with blood
• Loss of all or part of an arm or leg
• Bleeding in a victim who is now confused or unconscious
B • Bleeding
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
B • Bleeding (continued)
What is “life-threatening” bleeding?
Blood soaking the sheet or clothing Photo courtesy of Norman McSwain, MD, FACS, NREMT-P.
Blood spurting out of a wound
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
B • Bleeding (continued)
Wounds That Can Lead to Death from Bleeding (1 of 3)
Arm and Leg Wounds
• Most frequent cause of preventable
death from injury
• Bleeding from these wounds can be
controlled by direct pressure or a
tourniquet
Photo courtesy of Peter T. Pons, MD, FACEP.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
B • Bleeding (continued)
Wounds That Can Lead to Death from Bleeding (2 of 3)
Torso Junctional Wounds
• Neck, shoulder, and groin
• Bleeding can be controlled by direct
pressure and wound packing
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
B • Bleeding (continued)
Wounds That Can Lead to Death from Bleeding (3 of 3)
Chest and Abdominal Injuries - Front, back, or side
- Usually cause internal bleeding
• This bleeding CANNOT be stopped
outside the hospital
• These victims need rapid transport to a
trauma center
• Identify these patients to EMS providers
when they arrive
Multiple gunshot wounds Photo courtesy of Peter T. Pons, MD, FACEP.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding
Ensure
your safety.
Look for life-
threatening
bleeding.
Is a trauma
first-aid kit
available?
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding
No
Ensure
your safety.
Look for life-
threatening
bleeding.
Is a trauma
first-aid kit
available?
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding
Use any clean cloth or gauze.
Apply steady pressure directly
on the wound. No
Ensure
your safety.
Look for life-
threatening
bleeding.
Is a trauma
first-aid kit
available?
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Direct Pressure (1 of 3)
• Use your hand or fingers
- Use two hands, if at all possible
• Effective most of the time for external bleeding
- Direct pressure can stop even major arterial bleeding
• Bleeding control requires very firm, continuous pressure until relieved by medical responders
• To be effective, apply pressure with the victim on a firm surface to provide support
• Don’t release pressure to check the wound
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Direct Pressure (2 of 3)
• Use any clean cloth (for example, a shirt) to cover the wound
• If the wound is large and deep, try to “stuff” the cloth down into the wound
Photos courtesy of Adam Wehrle, NREMT-P.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Direct Pressure (3 of 3)
• Apply continuous pressure with
both hands directly on top of the
bleeding wound
• Push down as hard as you can
• Hold pressure until relieved
by medical responders
Photo courtesy of Adam Wehrle, NREMT-P.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Ensure
your safety.
Look for life-
threatening
bleeding.
Is a trauma
first-aid kit
available? Yes
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
Ensure
your safety.
Look for life-
threatening
bleeding.
Is a trauma
first-aid kit
available?
Where is the
wound? Arm or leg
Yes
C • Compression: Stop the Bleeding (continued)
?
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
Ensure
your safety.
Look for life-
threatening
bleeding.
Is a trauma
first-aid kit
available?
Where is the
wound? Arm or leg
Is a
tourniquet
available
immediately? Yes
C • Compression: Stop the Bleeding (continued)
?
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
Ensure
your safety.
Look for life-
threatening
bleeding.
Is a trauma
first-aid kit
available?
Where is the
wound? Arm or leg
Is a
tourniquet
available
immediately? Yes
Yes
C • Compression: Stop the Bleeding (continued)
?
Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
Apply above the bleeding site.
Tighten until the bleeding stops.
Ensure
your safety.
Look for life-
threatening
bleeding.
Is a trauma
first-aid kit
available?
Where is the
wound? Arm or leg
Is a
tourniquet
available
immediately? Yes
Yes
C • Compression: Stop the Bleeding (continued)
?
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
The Tourniquet
• A tourniquet is a device that stops the
flow of blood
• If applied correctly, the tourniquet will
stop blood flow into the extremity and
out of the wound
• Limiting blood loss may prevent the
patient from going into shock or
dying Photo courtesy of Norman McSwain, MD, FACS, NREMT-P.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Tourniquet Application
• Apply immediately if life-threatening bleeding is seen from an arm or a leg
• The tourniquet can be placed right on top of clothing, if necessary
• Place 2 to 3 inches above the bleeding wound (higher on the arm or leg)
- BUT… • DO NOT apply directly over the knee or elbow joints
- The bones of the joint will prevent the tourniquet from compressing the artery, so you won’t stop the bleeding
• DO NOT apply directly over a pocket that contains bulky items
- Anything in a pocket that is underneath a tourniquet will interfere with the function of the tourniquet
• Tighten the tourniquet until bleeding stops
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Tourniquet Types
Military research has shown these three tourniquets work the best
to control bleeding
Photo courtesy of Peter T. Pons,
MD, FACEP
Photo courtesy of Peter T. Pons,
MD, FACEP
Photo courtesy of Peter T. Pons, MD, FACEP
Combat Application Tourniquet
(C.A.T.)
SOF Tactical Tourniquet
(SOFTT)
Photo courtesy of Delfi Medical Innovations, Inc.
Emergency and Military
Tourniquet (EMT™)
1st Generation 2nd Generation
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
C.A.T. Tourniquet
The C.A.T. tourniquet is the
military’s preferred tourniquet
because it is easy to use and can
be rapidly applied
Photo courtesy of Composite Resources, Inc.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Application of a C.A.T. Tourniquet (1 of 9)
Step 1. Insert the wounded
extremity (arm or leg) through
the C.A.T.
Photo courtesy of Peter T. Pons, MD, FACEP.
Photo courtesy of Peter T. Pons, MD, FACEP.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Application of a C.A.T. Tourniquet (2 of 9)
Step 2. Pull the self-adhering band
tight, and securely fasten it back
on itself.
BE SURE TO REMOVE
ALL SLACK.
Photo courtesy of Peter T. Pons, MD, FACEP.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Application of a C.A.T. Tourniquet (3 of 9)
Step 3. Adhere the band around
the extremity. Do not adhere
the band past the clip.
Photo courtesy of Peter T. Pons, MD, FACEP. Photo courtesy of Peter T. Pons, MD, FACEP.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Application of a C.A.T. Tourniquet (4 of 9)
Step 4. Twist the windlass rod
until the bleeding has stopped.
Photo courtesy of Peter T. Pons, MD, FACEP.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Application of a C.A.T. Tourniquet (5 of 9)
Step 5. Lock the windlass rod
in place in the windlass clip.
Bleeding is now controlled.
Photo courtesy of Peter T. Pons, MD, FACEP.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Application of a C.A.T. Tourniquet (6 of 9)
Step 6. Adhere the remaining
self-adhering band over the rod,
through the windlass clip, and
continue around the extremity as
far as it will go.
Photo courtesy of Peter T. Pons, MD, FACEP.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Application of a C.A.T. Tourniquet (7 of 9)
Step 7. Secure the rod and the
band with the windlass strap.
Grasp the strap, pull it tight, and
adhere it to the opposite hook on
the windlass clip.
Photo courtesy of Peter T. Pons, MD, FACEP.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Application of a C.A.T. Tourniquet (8 of 9)
Step 8. Note the time the
tourniquet was applied. If you
have a marker, you can write it
directly on the tourniquet.
The patient is now ready for
transport.
Photo courtesy of Peter T. Pons, MD, FACEP.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Key Points (1 of 2)
• Using one of the recommended tourniquets is a safe procedure
- Improvised (homemade) tourniquets are much less effective than
commercially available tourniquets such as the C.A.T. and are difficult to
make and apply without extensive practice
• If the bleeding is not stopped with one
tourniquet and it is as tight as you can get it,
place a second one, if available, just above the
first and tighten as before
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Key Points (2 of 2)
• No amputations have been caused by a tourniquet when left in place for
fewer than two hours
- BUT… it is best to get the patient to a trauma center as soon as possible so
the bleeding can be completely controlled and the tourniquet removed
• Better to risk damage to the arm or leg than to have a victim bleed to death
• Training (practice) tourniquets should NOT be used during a real
patient incident
- Repetitive use during training exercises may cause the tourniquet to fail
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Tourniquet Pain • Tourniquets HURT when applied effectively (they HURT A LOT)
- Explain this fact to the victim
• Pain DOES NOT mean you put on the tourniquet incorrectly
• Pain DOES NOT mean you should take the tourniquet off
• Once paramedics arrive, they will treat the pain with medication
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Common Mistakes
• Not using a tourniquet or waiting too long to apply it when there is
life-threatening bleeding
• Not making the tourniquet tight enough to stop the bleeding
• Not using a second tourniquet, if needed
• Periodically loosening the tourniquet to allow blood flow to the
injured extremity
- Causes unacceptable additional blood loss—DO NOT LOOSEN
• Removing a tourniquet
- Only a paramedic or physician should loosen or remove it
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Questions
about
tourniquets?
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Tourniquet Practice
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
Ensure
your safety.
Look for life-
threatening
bleeding.
Is a trauma
first-aid kit
available?
Where is the
wound? Arm or leg
Is a
tourniquet
available
immediately? Yes
C • Compression: Stop the Bleeding (continued)
?
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
No
Ensure
your safety.
Look for life-
threatening
bleeding.
Is a trauma
first-aid kit
available?
Where is the
wound? Arm or leg
Is a
tourniquet
available
immediately? Yes
C • Compression: Stop the Bleeding (continued)
?
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
Use hemostatic (bleeding control)
gauze (preferred) or any gauze or
clean cloth.
Apply continuous, direct pressure. No
Ensure
your safety.
Look for life-
threatening
bleeding.
Is a trauma
first-aid kit
available?
Where is the
wound? Arm or leg
Is a
tourniquet
available
immediately? Yes
C • Compression: Stop the Bleeding (continued)
?
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
Use hemostatic (bleeding control)
gauze (preferred) or any gauze or
clean cloth.
Apply continuous, direct pressure. No
Ensure
your safety.
Look for life-
threatening
bleeding.
Is a trauma
first-aid kit
available?
Where is the
wound?
Neck,
shoulder,
groin
Arm or leg
Is a
tourniquet
available
immediately? Yes
C • Compression: Stop the Bleeding (continued)
?
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Hemostatic Dressings (Bleeding Control Dressings)
• Hemostatic dressings are materials that help cause blood to clot
• Examples of hemostatic dressings include:
- QuikClot (civilian) /
Combat Gauze (military)
- Celox
- Celox Rapid
- Chitoflex
- Chitogauze © emily2k/ShutterStock, Inc. Photo courtesy of Peter T. Pons, MD, FACEP.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Wound Packing (1 of 5)
• Open clothing around the wound
• If possible, remove excess pooled blood from the
wound while preserving any clots already formed
in the wound
• Locate the source of the most active bleeding
© Jones & Bartlett Learning. Photographed by
Darren Stahlman.
© Jones & Bartlett Learning. Photographed by
Darren Stahlman.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Wound Packing (2 of 5)
• Pack the wound
- Hemostatic dressing, OR
- Gauze roll, OR
- Clean cloth
• Stuff right into the wound and directly
onto the bleeding site
© Jones & Bartlett Learning. Photographed by Darren Stahlman.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Wound Packing (3 of 5)
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Wound Packing (4 of 5)
• Quickly apply and hold pressure
directly on the packed wound until
relieved by medical responders
• If initial packing and direct pressure
fail to stop the bleeding, pack a second
gauze on top of the first and reapply
pressure using increased force
© Jones & Bartlett Learning. Photographed by Darren Stahlman.
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Questions about
wound packing
and direct pressure?
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Wound Packing Practice
Primary Principles:
ABCs of Bleeding
C • Compression: Stop the Bleeding (continued)
Introduction | Principles | A-Alert | B-Bleeding | C-Compression | Bleeding Control Basic v. 1.0
Bleeding control in children
• In all but the extremely young child, the same
tourniquet used for adults can be used in children.
• For the infant or very small child (tourniquet too
big), direct pressure on the wound as described
previously will work in virtually all cases.
• For large, deep wounds, wound packing can be
performed in children just as in adults using the same
technique as described previously.
Bleeding Control Basic v. 1.0
Blood Exposure
• After arrival of medical responders, if you have
any blood on you:
- Wash thoroughly with soap and water to remove all blood,
AND
- Notify medical responders of possible exposure
Bleeding Control Basic v. 1.0
Summary
• Ensure your own safety
• The ABCs of Bleeding
A – Alert – call 9-1-1
B – Bleeding – find the bleeding injury
C – Compress – apply pressure to stop the bleeding by:
1. Covering the wound with a clean cloth and applying pressure by
pushing directly on it with both hands, OR
2. Using a tourniquet, OR
3. Packing (filling) the wound with gauze or a clean cloth and then
applying pressure with both hands
Bleeding Control Basic v. 1.0
Conclusion
Bleeding Control Basic v. 1.0
The only thing more tragic than a death…
is a death that could have been prevented.
Thank you for your participation.
Questions?
Personal bleeding control kits
Wall-mounted bleeding control kits
BLEEDINGCONTROL.ORG
For further information and additional
resources, please visit